Download An unusual case of anisocoria by vegetal intoxication: a case report

Macchiaiolo et al. Italian Journal of Pediatrics 2010, 36:50
http://www.ijponline.net/content/36/1/50
ITALIAN JOURNAL
OF PEDIATRICS
CASE REPORT
Open Access
An unusual case of anisocoria by vegetal
intoxication: a case report
Marina Macchiaiolo*, Elettra Vignati, Michaela V Gonfiantini, Annalisa Grandin, Maria Teresa Romano,
Michele Salata, Diletta Valentini, Alberto Villani
Abstract
A 12 year old boy presented with an acute onset of anisocoria and blurred vision. Ocular motility was normal but
his right pupil was dilated, round but sluggishly reactive to light. There was no history of trauma, eye drops’ instillation, nebulised drugs or local ointments. His past medical history was negative.
A third nerve palsy was considered but the performed cerebral MRI was normal.
On further anamnestic investigation the boy revealed that he had spent the morning doing gardening, and especially working on a “trumpet plant”. Datura and Brugmansia are well known toxic plant; all Datura and Brugmasia
plants contain, primarily in their seeds and flowers, tropane alkaloids such as scopolamine, hyoscyamine and atropine. Systemic and local intoxications have already been described.
The day after anisocoria was much less evident and completely resolved in three days.
We present this case of an unusual cause of mydriasis to underline once more the importance of a well and
deeply conducted medical history.
Case report
A 12 year old boy presented to the emergency for the
onset of acute anisocoria. Two hours before the boy had
started to complain of a blurred vision; his mother, a
paediatric nurse, noticed a pupil asymmetry with a
clearly dilated right pupil (Figure 1). Eyes were normal
at wake up and during the early morning; the boy had
spent the all morning playing in grandmother’s garden.
There was no history of trauma, eye drops’ instillation,
nebulised drugs or local ointments. His past medical
history was negative.
On physical examination the boy was well, orientated
and collaborative. In room light the right pupil was
round, but the reaction to light was sluggish. Left eye’s
reaction was normal. Anisocoria was more evident in
bright light. Ocular motility was normal. On slit lamp
the pupil was round and no signs of trauma were
detected. Consensual pupillary light reflex of the left eye
was elicited. In the anterior chambers no inflammatory
changes were detected and both irises and fundi examination were normal.
* Correspondence: [email protected]
U.O.C Pediatria Generale Dipartimento di Medicina Pediatrica, Ospedale
Pediatrico Bambino Gesù, P.zza Sant’Onofrio 4, 00165 Roma, Italy
A third nerve palsy was considered but the performed
cerebral MRI was normal.
On further investigation the boy explained that he had
spent the morning doing gardening and especially working on a “trumpet plant”. A quick internet search helped
to find a picture of “ Datura suaveolens “, commonly
known as trumpet plant, immediately recognized by the
child and his mother (Figure 2). The boy did not refer a
direct contact of leaves or flowers with eyes, however he
referred to have handled both leaves and flowers and to
have removed new small plants arising at the bottom of
the plant. It is very likely that an accidental hands-eye
contact after touching the plant had occurred.
The day after anisocoria was much less evident and
completely resolved in three days. The patient was diagnosed with pharmacologic mydriasis secondary to unintentional contact with Datura suaveolens ; no further
investigations were performed and the boy completely
recovered.
Discussion
Causes of a mydriasis, more evident in light, are trauma,
third nerve palsy, Adie’s pupil and pharmacologic
mydriasis [1].
© 2010 Macchiaiolo et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Macchiaiolo et al. Italian Journal of Pediatrics 2010, 36:50
http://www.ijponline.net/content/36/1/50
Figure 1 Evident right mydriasis.
Figure 2 Datura suaveolens.
Our patient had no neurologic symptoms, there was
no ptosis nor an ocular motility deficit. However, a cerebral MRI was performed to exclude a compressive origin
of palsy even if the level of suspicion of this cause was
very low.
An Adie’s pupil due to an injury to the ciliary ganglion can be secondary to viral infection, trauma or cancer. To differentiate it from other causes of mydriasis a
pilocoarpine test with low concentration (0.1%) can be
useful. Pilocarpine will cause constriction of the pupil
due to denervation sensitivity, while no constriction is
detected in case of oculomotor palsy or pharmacological
mydriasis.
Differentiation between paralytic and pharmacologic
mydriasis can be made by using a 1% pilocarpine eye
drops test. Dilated pupils do not constrict in response to
pilocarpine 1% in pharmacologic mydriasis, but do in
paralytic mydriasis. Also mydriasis secondary to a traumatism does not respond to drops, but in this case
Page 2 of 3
there was no history nor any objective sign of trauma
on slit lamp examination [2]. Furthermore this test may
not always be reliable. In the case of pharmacological
mydriasis due to an uncontrolled toxicity exposure, the
concentration of alkaloids is unpredictable; if the degree
of toxicity is low, mydriasis may be present but it can
be overcame with pilocarpine drops.
In this case, a detailed medical history helped to final
diagnosis of pharmacologic mydriasis by revealing the
exposure to an ornamental plant, called angel’s trumpet,
frequently found in gardens. Accidental mydriasis from
exposure to plant components has been reported in
humans and animals [2]. Brugmansia is a genus of
seven species of flowering plants of the family Solanaceae native from subtropical regions of South America.
They are known as angel’s trumpets, sharing that name
with the closely related genus Datura, well known toxic
plants of the Solanaceae family.
All Brugmansia and Datura plants contain, primarily
in their seeds and flowers, tropane alkaloids such as scopolamine, hyoscyamine and atropine. Because of the
presence of such substances, these plants have been
used for centuries in some cultures as poison and hallucinogen [2,3].
Flowers that can induce parasympatholytic effects in
the eye are well known: deadly nightshade (Atropa belladonna), angel’s trumpet (Brugmansia arborea), thorn
apple or jimsonweed (Datura stramonium), and black
henbane (Hyoscyamus niger).
The Brugmansia genus (angel’s trumpet) contains a
concentration of tropane alkaloids ranging from 2,5 mg/g
to 7 mg/g per blossom, 0.20 mg of atropine and 0.65 mg
of scopolamine [3]. In Datura (thorn apple) the seeds
have the highest alkaloid content of the plant: 2.71 mg/g
of atropine and 0.66 mg/g of scopolamine; leaves of the
thorn apple contain 0.2 to 0.45 mg/g of total alkaloids.
The alkaloid concentration is always referred to grams of
fresh plant weight.
Andreola et al (2008) reported a very similar case [4],
with rapid onset of symptoms after exposure; authors
have analysed alkaloid content in the different parts of
the flower. Their analysis showed that the maximum
alkaloid content is present in the corolla tissue along
the ribs; authors [4] remark that the abundant occurrence of glandular hairs on the rib regions suggests that
these alkaloids might be present not only in the epidermal cells but also in the glandular hairs explaining why
intoxication may occur, following simple contact of the
eye with the plant surface, which is characterized by
high densities of glandular hairs that can be easily
broken.
However alkaloid concentration in leaves, stems, flowers and seeds of an individual plant differ markedly; it
even changes with season and hydration.
Macchiaiolo et al. Italian Journal of Pediatrics 2010, 36:50
http://www.ijponline.net/content/36/1/50
That’s why it is almost impossible to determine the
exact dose of alkaloids in the plant component that
comes in contact with the eye.
Ingestion of 10 to 50 mg of atropine appears to be
toxic for adults, 4 to 5 mg may be fatal for small children. The duration of the mydriasis after exposure to a
plant component varies from 24 hours to 1 week. The
presentation of the mydriasis can differ from a maximally dilated and non-responsive pupil to variable
degrees of light responses. Systemic intoxication by
ingestion has been widely described. Symptoms of
Datura toxicity occur typically within 60 minutes after
ingestion and continue for 24-48 hours. Ingestion of
Datura manifests as a classic anticholinergic syndrome
comprising central and peripheral signs and symptoms
[5,6].
By help of the well conducted anamnesis our patient
was diagnosed with pharmacologic mydriasis secondary
to unintentional contact with Datura suaveolens ; no
further investigations were performed and the boy completely recovered.
Page 3 of 3
4.
5.
6.
Andreola B, Piovan A, Da Dalt L, Filippini R, Cappelletti E: Unilateral
mydriasis due to Angel’s Trumpet. Clinical Toxicol 2008, 46(4):329-331.
Goetz R, Siegel El, Scaglione J: Suspected Moonflower Intoxication —
Ohio, 2002. MMWR 2003, 52(33):788-791.
Klein-Schwartz W, Oderda GM: Jimsonweed intoxication in adolescents
and young adults. Am J Dis Childhood 1984, 138:737-9.
doi:10.1186/1824-7288-36-50
Cite this article as: Macchiaiolo et al.: An unusual case of anisocoria by
vegetal intoxication: a case report. Italian Journal of Pediatrics 2010 36:50.
Conclusions
This case highlights once more the importance of a well
conducted medical history Suspicion of an accidental
intoxication should always arise when unilateral mydriasis is found in patients without evidence of a retrobulbar
or intracerebral process. Questions about playing or
working in the garden should always be asked. We performed an instrumental exam like cerebral MRI, with an
earlier and deeper anamnestic investigation this exam
could have been avoided.
Consent
Written informed consent was obtained from the
patient’s parents for publication of this case report and
for the use of image in this case report. A copy of the
written consent is available for review by the Editor-inChief of this journal.
Authors’ contributions
All authors have participated in the diagnostic pathways, all authors have
read and approved he final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 4 March 2010 Accepted: 20 July 2010 Published: 20 July 2010
References
1. Firestone D, Sloane C: Not your everyday anisocoria: angel’s trumpet
ocular toxicity. The J Emerg Med 2007, 33:21-24.
2. Van der Donck I, Mulliez E, Blanckaert J: Angel’s trumpet (Brugmansia
arborea) and mydriasis in a chid - a case report. Bull Soc Belge Ophtal
2004, 292:53-56.
3. Adams JD, Garcia C: Spirit, Mind and Body in Chumash Healing.
Evidence-based. Complement and Alternative Med 2005, 2:459-463.
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